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Childbirth at Risk: Labor Complications

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  1. Childbirth at Risk: Labor Complications Twila Brown, PhD, RN

  2. Dystocia and Dysfunctional Labor • Causes • Power • Hypotonic • Hypertonic • Passenger • Passage

  3. Dysfunctional Uterine Contractions: Hypertonic Labor Patterns • Latent phase of labor • Contractions • Ineffective in dilating and effacing the cervix • Resting tone of myometrium increases • Occur more frequent • Painful • Maternal risks • Fetal risks

  4. Dysfunctional Uterine Contractions: Hypertonic Labor Patterns • Management • Assess for cephalopelvic disproportion (CPD) • Bed rest and sedation • Oxytocin or amniotomy • Decrease pain and anxiety • Monitor fetal heart rate patterns • Provide fluids and glucose

  5. Dysfunctional Uterine Contractions: Hypotonic Labor Patterns • Active phase of labor • Etiology • Sedation, over-distension of the uterus, bladder or bowel distention • Advancing maternal age • Contractions • Low amplitude • Fewer than 2-3 contractions in 10 minutes • Irregular pattern • Cervical dilation less than 1 cm per hour

  6. Dysfunctional Uterine Contractions: Hypotonic Labor Patterns • Management • Assess for CPD and engagement • Amniotomy • Oxytocin • Provide comfort and decrease anxiety • Monitor mother • Monitor fetus

  7. Precipitous Labor and Birth • Labor and birth less than 3 hours • Intense contractions • Little relaxation between contractions • Rapid cervical dilation and fetal descent • Maternal risks • Fetal risks

  8. Precipitous Labor and Birth • Management • Tocolytic agent • Immediate delivery • Support for relaxation • Monitor contractions and fetal heart rate • Apply pressure to fetal head

  9. Fetal Position • Most common at delivery • Cephalic – Vertex • Chin flexed to chest • Occiput Anterior

  10. Fetal Malposition: Occiput-posterior • Assessment • Intense back pain • Poor dilatation and descent • Depression in lower maternal abdomen • Fetal heart rate heard laterally • Anterior fontanelle in anterior • Perineal laceration or episiotomy extension • Management • Manual rotation • Side-lying or knee-chest • Forceps

  11. Fetal Malpresentation: Military, Brow, and Face • Management • Cesarean birth if CPD • Monitor for fetal hypoxia • Episiotomy extension • Forceps or manual conversion contraindicated • Newborn trauma

  12. Fetal Malpresentation: Breech • Assessment • Fetal head, feet, bottom, and heart tones • Management • External cephalic version • Cesarean delivery • Small maternal pelvis • Fetal weight <1500gm or >3800gm • Neck hyperextension, arms over head, anomalies • If vaginal delivery • Pain management, prolapsed cord, head trauma

  13. Fetal Malpresentation: Shoulder (Transverse lie) • Assessment • Maternal abdomen • Fetal head • Presenting part • Management • External version attempted • Cesarean delivery • Monitor for prolapsed cord

  14. Multiple Gestation • Risks • Hypertension or preeclampsia, anemia, hydramnios • Preterm birth, abnormal fetal presentation • Overstretched uterus, postpartum hemorrhage • Monochorionic placenta or Monoamniotic • Management • Prevent preterm labor • Monitor each fetus • May have Cesarean delivery

  15. Nonreassuring Fetal Status: Fetal Distress • Etiology • Uteroplacental insufficiency • Fetal hypoxia • Assessment • Late or severe variable decelerations • Decrease in variability • Changes in baseline • Meconium staining of amniotic fluid • Fetal scalp blood pH below 7.20

  16. Nonreassuring Fetal Status • Management • Maternal position • Increase intravenous fluid • Oxygen • Discontinue oxytocin • If fetal distress continues, cesarean delivery and resuscitate • If delivery is imminent, deliver and resuscitate

  17. Cephalopelvic Disproportion (CPD) • Signs • Slow cervical dilation and effacement • Lack of fetal engagement and descent • Maternal risks • Prolonged labor • Premature rupture of membranes • Uterine rupture • Fetal risks • Prolapsed umbilical cord • Head trauma

  18. Cephalopelvic Disproportion • Management • Monitor progression of labor • Monitor for fetal distress • Emotional support • Cesarean delivery • Maternal position McRoberts maneuver

  19. Prolapsed Umbilical Cord • Etiology • Not engaged when membranes rupture • Contributing factors • Assessment • Cord through the cervix • Fetal heart rate is irregular • Cord compressed • Occludes blood flow to fetus • Compression worsens during contractions • Emergency

  20. Prolapsed Umbilical Cord • Management • Bed rest until engagement if ruptured membranes • Relieve cord pressure • Push back the presenting part • Fill bladder • Change maternal position • Administer oxygen • Monitor fetal heart tones • Cesarean delivery

  21. Abruptio Placentae • Etiology • Decreased blood flow to the placenta • Maternal hypertension, abdominal trauma, cocaine • Maternal risks • Hypoxic uterus • Uterus difficult to contract after delivery • Maternal hemorrhagic shock • Fetal/neonatal risks • Complications from preterm labor, anemia, and hypoxia

  22. Abruptio Placentae • Assessment • Fundal height increases • May or may not have vaginal bleeding • Painful • Irritable uterus • Rigid, boardlike abdomen • Enlarged uterus • Signs of shock

  23. Abruptio Placentae • Management • Monitor vital signs and fetal heart tones • Assess vaginal bleeding, pain, and fundal height • Bed rest • Administer oxygen, IV fluids, and blood products • Monitor and treat hypovolemia • Induce vaginal delivery if mild separation: • Cesarean delivery for moderate to severe separation or fetal distress

  24. Placenta Previa • Etiology • Placenta implanted in lower uterine segment • Placental villi are torn from uterus • Signs • Painless, bright red vaginal bleeding • Soft, nontender uterus • High presenting part • Types • Low-lying, Partial, Total

  25. Placenta Previa • Management • Monitor vital signs, fetal heart rate, fetal activity • Assess amount and quality of bleeding • Vaginal exam is contraindicated • Ultrasound • Administer oxygen as prescribed for fetal distress • Preterm: Bed rest and monitor • Term with low-lying or marginal: Induce for delivery • Cesarean if complete previa or fetal distress

  26. Intrauterine Fetal Death • Loss of heart rate on ultrasound and drop in maternal estriol levels • Induce labor or spontaneous labor within 2 weeks • Parental reaction • Supportive care

  27. References • Ladewig, P.A., London, M.L., & Davidson, M.R. (2006). Contemorary maternal-Newborn Nursing Care (6th ed.). Upper Saddle River, NJ: Prentice Hall. • Littleton, L.Y., & Engebretson, J.C. (2005). Maternity nursing care. Clifton Park, NY: Thomson Delmar Learning. • Olds, S.B., London, M.L., Ladewig, P.W., & Davidson, M.R. ( 2004). Maternal-newborn nursing & women’s health care (7th ed.). Upper Saddle River, NJ: Prentice Hall. • Silvestri, L.A. (2002). Saunders comprehensive review for NCLEX-RN (2nd ed.). Philadelphia: W.B. Sanders. • Straight A’s in maternal-neonatal nursing. (2004). Philadelphia: Lippincott Williams & Wilkins.